Local and Regional Anesthesia最新文献

Emergence from anesthesia can be associated with a wide spectrum of cognitive and behavioral dysregulation in children, including delirium or acute brain dysfunction. This period of neurobehavioral recovery can be further confounded by pain, anxiety, and fear. The implementation of monitoring for level of consciousness, pain, and delirium using valid pediatric tools is necessary to avoid misdiagnosis due to overlapping symptomatology and support appropriate management. Understanding the epidemiology of delirium in the postoperative setting will require consistent use of accurate terminology in the medical literature. The current interchangeable use of the terms "emergence agitation" and "emergence delirium" needs to be highlighted and awareness of differences in patient conditions and assessment tools is essential. We discuss epidemiology of emergence agitation and delirium in the pediatric population, and the challenges for future delineation of monitoring and management. Furthermore, we describe the possible impact of long-term consequences of emergence delirium among infants and children, and the necessary areas of future research.

Surgery is a critical period in the survival of patients with cancer. While resective surgery of primary tumors has shown to prolong the life of these patients, it can also promote mechanisms associated with metastatic progression. During surgery, patients require general and sometimes local anesthetics that also modulate mechanisms that can favor or reduce metastasis. In this narrative review, we summarized the evidence about the impact of local, regional and general anesthesia on metastatic mechanisms and the survival of patients. The available evidence suggests that cancer recurrence is not significantly impacted by neither regional anesthesia nor volatile or total intravenous anesthesia.

Intractable headaches can be debilitating, often leading to significant distress, prolonged medical treatment, and unanticipated hospital admissions. There have been significant advances in the treatment of primary intractable headaches such as migraines, tension headaches, and cluster headaches beyond medical management. Treatments may now include interventional strategies such as trigger-point injections, peripheral nerve stimulators, or peripheral nerve and ganglion blocks. There are few studies, however, describing the use of interventional techniques for the management of intractable secondary headaches, including those attributed to injury or infection. A new regional anesthetic technique, the erector spinae plane (ESP) block, was initially used for neuropathic thoracic pain. ESP block has since been reported to provide acute and chronic pain relief of the shoulder, spine, abdomen, pelvis, thorax, and lower extremity. Additionally, there has been one case report to describe the use of the ESP block in the treatment of refractory tension headache. We report four cases of effective analgesia for intractable secondary headache resistant to medical management with high thoracic ESP blocks. In each case, the ESP block provided instant pain relief. We suggest that the findings of this case series indicate that the ESP block may be a useful intervention in patients with severe secondary headache or posterior cervical pain where conventional therapies have limited success, though more studies are necessary.

Spinal anesthesia-induced hypotension (SAIH) occurs frequently, particularly in the elderly and in patients undergoing caesarean section. SAIH is caused by arterial and venous vasodilatation resulting from the sympathetic block along with a paradoxical activation of cardioinhibitory receptors. Bradycardia after spinal anesthesia (SA) must always be treated as a warning sign of an important hemodynamic compromise. Fluid preloading (before initiation of the SA) with colloids such as hydroxyethyl starch (HES) effectively reduces the incidence and severity of arterial hypotension, whereas crystalloid preloading is not indicated. Co-loading with crystalloid or colloid is as equally effective to HES preloading, provided that the speed of administration is adequate (ie, bolus over 5 to 10 minutes). Ephedrine has traditionally been considered the vasoconstrictor of choice, especially for use during SAIH associated with bradycardia. Phenylephrine, a α₁ adrenergic receptor agonist, is increasingly used to treat SAIH and its prophylactic administration (ie, immediately after intrathecal injection of local anesthetics) has been shown to decrease the incidence of arterial hypotension. The role of norepinephrine as a possible alternative to phenylephrine seems promising. Other drugs, such as serotonin receptor antagonists (ondansetron), have been shown to limit the blood pressure drop after SA by inhibiting the Bezold-Jarisch reflex (BJR), but further studies are needed before their widespread use can be recommended.

Introduction: Brachial plexus blocks are frequently practiced and safe mode of anaesthsia. Although minor complications may occur, major complications are a rarity. However, we report a rare case of prolonged supraclavicular brachial plexus block which required almost 4 months to recover without a perceivable cause.

Case presentation: A 22-year-old gentleman posted for open reduction and internal fixation of both forearm bones was administered an ultrasound-guided supraclavicular brachial plexus block. The intra-operative period was uneventful. However, the block persisted for a very prolonged period of time. All perceivable causes were ruled out. A total of 19 weeks was required for the entire block to regress with no residual neurological deficits thereafter.

Conclusion: Although peripheral neuropathies are known complications of peripheral nerve blocks, such a prolonged brachial plexus block is a rare event. The only plausible cause for the patient's condition could have been the prolonged drug effect; however, it has been rarely documented.

Acute subdural hematoma (aSDH) is commonly encountered in the emergency department in patients with traumatic injuries. If the hematoma is small, non-expanding and asymptomatic, it is managed conservatively. However, other injuries sustained during trauma may warrant surgical intervention, during which anesthetic management becomes challenging. There have been reports of rebleeding in patients with aSDH after undergoing surgery under either general or spinal anesthesia. Here we present a case where ankle surgery for tri-malleolar fracture was successfully performed in a patient with traumatic aSDH under combined lumbar plexus and proximal (para-sacral) sciatic nerve block.

Background: The purpose of this study is to evaluate the safety and efficacy of oral melatonin administered with thoracic epidural analgesia in patients with multiple bilateral fractured ribs.

Patients and methods: A prospective, double-blind randomized control study was carried out on 80 patients of either sex, American Society of Anesthesiologists (ASA) Grade I and II, aged above 18 years, presenting with multiple bilateral fractured ribs. They were randomly divided into two groups, 40 patients each. Placebo group patients received oral placebo tablets and melatonin group (TEA and melatonin) patients received oral melatonin tablets (5 mg), about 1 hour before epidural infusion of local anesthetics and then every 12 hours till the cessation of bupivacaine infusion.

Results: Melatonin administration was associated with a significant decrease in total morphine analgesia consumption, from 31.8 ± 1.41 mg in the TE group to 13.03 ± 0.85 mg in the melatonin group (P < 0.001), with a significant decrease (P < 0.001) in the mean infusion rate of bupivacaine required for controlling the pain, from 0.17 ± 0.014 mL/kg/hour in the TE group to 0.12 ± 0.001 mL/kg/hour in the melatonin group. The duration of bupivacaine infusion in the melatonin group was also significantly shorter than in the TE group (96.48 ± 1.87 and 100.05 ± 3.39 hours, resp., P < 0.001).

Conclusion: We conclude that premedication of patients with 5 mg melatonin is associated with significant prolongation of thoracic epidural analgesic effects compared to placebo.

Registration: This clinical study was registered at Pan African Clinical Trial Registry with no. "PACTR 201711002741378" on 02-11-2017.

Introduction: Post-operative pain control following cesarean section delivery (CD) is an important topic of discussion given the lack of consensus on a narcotic-sparing analgesic regimen. We describe the case of an elective CD with narcotic-free pain control using continuous bilateral posterior quadratus lumborum (QL) blockade as the primary mode of analgesia.

Case report: The patient is a 36-year-old female, G3P1, who presented at 37 weeks of gestation in active labor scheduled for elective primary CD. A spinal anesthetic was performed at L4-L5 with hyperbaric 0.75% bupivacaine, without intrathecal morphine. Bilateral posterior QL catheters were placed under sterile conditions with 20 mL of 0.25% bupivacaine per side. Continuous infusion of 0.2% ropivacaine was then started at 10 mL/hour per side. The patient's pain was controlled with QL catheters and a multimodal pain regimen consisting of non-steroidal anti-inflammatory drugs and acetaminophen. The patient reported a resting pain score of 0 with a dynamic pain score of 3 out of 10 throughout her recovery. She was discharged on post-operative (post-op) day 3 and the catheters were removed without any complications.

Discussion: The gold standard for pain control following CD is intrathecal morphine; however, its use has many adverse effects. Bilateral single-shot QL blocks following CD have been proven to decrease opioid consumption but its limited duration has minimal advantage over intrathecal morphine and patients continue to require oral narcotics for analgesia. With the use of QL catheters and a multimodal pain regimen, it may be possible to achieve opioid-free CD for the post-op period.